Failure to Administer Prescribed Pain Medication for Three Consecutive Days
Penalty
Summary
Nursing staff failed to administer a prescribed opioid pain medication, tramadol, to a resident for three consecutive days, resulting in a significant medication error. The resident, who had severe cognitive impairment and was at risk for pain, had a physician's order for daily tramadol and as-needed acetaminophen for pain management. The medication administration record showed that the last dose of tramadol was given, after which the medication ran out and was not refilled in a timely manner. Nurses documented the absence of tramadol and initiated the refill process, but delays occurred due to the need for a nurse practitioner's signature and pharmacy delivery schedules. During the period when tramadol was unavailable, the resident received as-needed acetaminophen for mild pain, with pain assessments documented as low or absent. Despite the lack of tramadol, there were no documented progress notes on one of the days, and communication between nursing staff and the pharmacy was ongoing to resolve the medication shortage. The facility's emergency medication supply (Pyxis) contained tramadol, but it was not accessed for the resident during the lapse. Interviews with nursing staff and the nurse practitioner confirmed the medication error and acknowledged that the incident could have been avoided with earlier action. The Director of Nursing stated that refills for controlled medications should be initiated several days in advance to prevent such gaps. The administrator and DON both noted that the resident did not experience significant pain during the lapse, but the failure to administer tramadol as ordered constituted a significant medication error.